Assessment & Classification DSM Notes

Chapter Two: Assessment & Classification DSM Style

Introduction

  • Context of Responsibility in Society:

    • Society's uncertainty in assigning responsibility involves multiple entities: law enforcement, religion, psychiatry, the family, and social planning.

    • Psychiatry's role is valued for asserting and validating illness models and therapeutic interventions.

    • Significant progress over 40 years includes establishing trust in psychiatry for identifying and effectively treating mental disorders.

  • Quotations Reflecting Philosophical Views:

    • William Carpenter (2002): Highlights society’s confidence in psychiatry's ability to identify mental disorders and provide effective treatment.

    • Kevin Throop: Compares celestial navigation based on false premises to the utility of incorrect models in understanding behaviors.

    • Fritzof Capra: Notes the difficulty in recognizing the limitations of conceptual knowledge and the tendency to confuse representation with reality.

1. Assessment Based Upon Traditional Intrapsychic Epistemology

  • Framework Overview:

    • Follows the medical model and makes dispositional assumptions.

    • Infers personality traits and locates problems within the individual, particularly in the unconscious mind.

  • Methods of Assessment:

    • Clinical Interviews: Direct discussions to understand the individual’s experiences.

    • Free Association: Encourages spontaneous verbalization to uncover unconscious thoughts.

    • Projective Tests:

    • Rorschach and Thematic Apperception Test (TAT) allow clients to project meanings onto neutral stimuli.

    • Assumes unconscious material can be accessed through responses.

    • Dream Analysis: Explores dreams to gather insight into unconscious conflicts and desires.

  • Diagnosis Procedure:

    • Information gathered is interpreted by the therapist, leading to a constructed diagnosis.

    • Emphasizes underlying pathology over visible symptoms.

    • Objective Testing: Uses instruments like the MMPI and Wechsler IQ to supplement assessments.

2. Assessment Based Upon Behavioral Epistemology

  • Focus on Situational Determinants:

    • Highlights the importance of context for understanding behaviors.

    • Investigates four variables:

    1. Stimuli: Environmental circumstances triggering behaviors.

    2. Organismic Factors: Present biological or situational conditions (medications, diseases).

    3. Responses: Detailed description of behaviors, including frequency and intensity.

    4. Consequences: Reinforcers or outcomes post-behavior that influence its persistence.

  • Assessment Characteristics:

    • Symptom-focused and devoid of assumptions about underlying mechanisms.

    • Emphasizes that symptom removal is important and that symptom substitution is generally avoided.

    • Supported by substantial behavioral data.

3. Assessment Based Upon a Systems Epistemology

  • Systems Framework:

    • Similar to behavioral assessment but examines familial and cultural influences contributing to meaning-making.

    • Moves towards understanding relationships rather than isolated behaviors, emphasizing circular causality and reciprocal interactions.

  • Conceptual Focus:

    • Examines system boundaries, rules, roles, and intergenerational influences.

    • Example:

    • A wife who drinks due to anxiety faces rejection from her husband, mirroring familial patterns that repeat.

  • Behavior Dynamics:

    • Problem behaviors arise from individuals' meaning constructions about events and can inadvertently sustain destructive patterns.

    • Example of a drinking cycle leading to divorce highlights the complexity of relational dynamics.

  • Communication through Symptoms:

    • Symptoms are seen as messages within the system, indicative of larger relational issues.

4. DSM Diagnosis: The Quest for Order From Disorder

  • Purpose of DSM:

    • Aims to create diagnostic order amidst abnormal behaviors, serving as one representation among many potential classifications.

  • Political Dimensions:

    • DSM reflects cultural views and can be utilized as a control mechanism in broader societal contexts.

    • Labeling individuals can lead to exclusion, institutionalization, and can alter treatment dynamics (e.g., adolescents becoming wards of the state).

  • Caution Against Misleading Language:

    • Advocates for awareness regarding terminologies like ego, id, and superego that may obscure understanding rather than clarify.

5. DSM Classification Changes with DSM-5

  • Multiaxial Structure Evolution:

    • DSM-5 revisions combined previous Axes into a more streamlined diagnostic approach.

  • Current Structure:

    • Axis I: Broad range of mental health disorders now combined with previous medical concerns.

    • Major Diagnostic Categories Include:

    • Neurodevelopmental Disorders

    • Schizophrenia Spectrum and Other Psychotic Disorders

    • Bipolar and Related Disorders

    • Depressive Disorders

    • Anxiety Disorders

    • Obsessive-Compulsive and Related Disorders

    • Trauma- and Stressor-Related Disorders

    • Dissociative Disorders

    • Somatic Symptom and Related Disorders

    • Feeding and Eating Disorders

    • Sleep-Wake Disorders

    • Sexual Dysfunctions

    • Gender Dysphoria

    • Disruptive, Impulse-Control, and Conduct Disorders

    • Substance-Related and Addictive Disorders

    • Personality Disorders

  • Former Axes Eliminated:

    • Axis IV (Psychosocial Stressors) and Axis V (Global Functioning) were removed in DSM-5.

    • Clinicians must now consider the broader context without separate rating scales.

6. LABELING AND RELATED PROBLEMS

  • Challenges of Labeling:

    • Results in loss of nuanced understanding; oversimplifies individuals to single narratives.

    • Consequences of 'Filespeak':

    • Encourages pathological language that can become a self-fulfilling prophecy, limiting individual agency.

    • Creates binary distinctions instead of recognizing a continuum of behaviors.

    • Stigmatizes individuals and may contribute to unsolvable problems.

7. PRIMARY AND SECONDARY DEVIANCE: A SOCIOLOGICAL NOTION

  • Definitions:

    • Primary Deviance: Initial acts that occur without societal reaction.

    • Secondary Deviance: Behavior resulting from responses to societal labeling and consequences.

  • Process of Deviance:

    1. Primary Act: E.g., a teenager breaking curfew.

    2. Social Penalties: Family punishes the act (e.g., grounding).

    3. Subsequent Deviance: Further breaking of rules follows harsher penalties.

    4. Escalation: Leads to increased resistance and finally, formal community action.

    5. Career in Deviance: Acceptance of identity as a “troublemaker” can develop over time.

8. Reliability of Diagnosis Between Clinicians

  • Statistical Reliability by Conditions:

    • Research indicates the following agreement levels among clinicians:

    • Schizophrenic Disorders: 0.82

    • Paranoid Schizophrenia: 0.73

    • Anxiety Disorders: 0.74

    • Mood Disorders: 0.77

    • Personality Disorders: 0.47

    • Reliability Thresholds: Values above 0.70 indicate good reliability; below 0.40 is poor.

9. Cultural Considerations in DSM-5

  • Evolving Terminology:

    • “Racialized” replaces conventional terminology to denote socially constructed nature of race.

    • “Ethnoracial” combines ethnic and racial identities relevant to U.S. Census.

    • Avoidance of terms like “minority” to eradicate conditions perpetuating social hierarchies.

    • Promotion of gender-inclusive language with “Latinx.”

  • Cultural Sensitivity in Diagnosis:

    • Awareness of symptom expression variations among ethnoracial groups; inclusion of risk of misdiagnosis in marginalized populations.

    • Introduction of a Cultural Formulation Interview (CFI) in DSM-5 to facilitate culturally competent diagnosis.

    • Importance of understanding cultural context to enhance diagnostic assessment and clinical management.

  • Instructor Note on DSM Updates:

    • Mention of the instructor’s decision not to revise the document for time constraints, not due to disagreement with DSM-5 updates.